Petition for the Appointment of an Emergency Guardian And/Or Conservator for a Proposed Ward

PETITION FOR THE APPOINTMENT OF AN

EMERGENCY GUARDIAN AND/OR CONSERVATOR FOR A PROPOSED WARD

INSTRUCTIONS

Specific Instructions

This form is to be used for filing a Petition for the Appointment of an Emergency Guardian and/or Conservator for a Proposed Ward pursuant to O.C.G.A. §§29414 and/or 29-5-14.
In determining if this Court is the proper place to bring this action, Petitioner(s) should consult Georgia law, including but not limited to, Chapters 4, 5 and 11 of Title 29, as applicable.
Regarding the need for the pre-hearing appointment of an Emergency Guardian/Emergency Conservator, O.C.G.A. §§29-4-15(c)(5) and 29-5-15 (c)(5) provide as follows: If the court determines that there is probable cause to believe that the Proposed Ward is in immediate need of an emergency guardian, the court shall appoint apre-hearing emergency guardian to serve until the emergency hearing, with or without prior notice to the Proposed Ward, but only if the threatened risk is so immediate and the potential harm so irreparable that any delay is unreasonable and the existence of the threatened risk and potential for irreparable harm is certified by the affidavit of a physician licensed to practice medicine under Chapter 34 of Title 43, a psychologist licensed to practice under Chapter 39 of Title 43, or a licensed clinical social worker. However, pending the emergency hearing, the court shall order that no withdrawals may be made from any account on the authority of the Proposed Ward’s signature without the court’s prior approval and that the emergency conservator shall not expend any funds of the Proposed Ward without prior court approval.
Further, if a pre-hearing emergency guardian/emergency conservator is appointed to serve until the emergency hearing, then such guardian and/or conservator shall, prior to the issuance of Letters of Emergency Guardianship/Emergency Conservatorship, take an oath and post such bond as the court may require.
In any case involving the creation of a Conservatorship when the Proposed Ward owns real property in Georgia, a certificate of creation of conservatorship will be completed by the Clerk of the Probate Court and filed with the Clerk of the Superior Court of each county in which the Proposed Ward owns real property within thirty (30) days of the date of such order.
The burden of proof is on the Petitioner to present clear and convincing evidence that the Proposed Ward lacks sufficient capacity to make or communicate significant responsible decisions concerning his orher health or safety and is in need of a guardianship AND/ORthat there is an immediate, clear, and substantial risk of death or serious physical injury, illness, or disease unless an emergency guardian is appointed and/or that the Proposed Ward lacks sufficient capacity to make or communicate significant responsible decisions concerning the management of his or her property and is in need of a conservatorship AND that there is an immediate, substantial risk of irreparable waste or dissipation of the estate unless an emergency conservator is appointed.
The Certificate to the Secretary of State page is to be used only when a determinative finding has been made that the Proposed Ward’s voting rights should be removed due to the lack of capacity of the ward. The order of the Court must be modified to reflect that this right was removed. The certificate must be mailed to the Secretary of State.
The Certificate to the GBI page shall be used in all cases where a Guardianship and/or Conservatorship is/are established. Individuals so listed in this database will be prohibited from obtaining a weapons carry license. In the event the ward’s rights are restored, such restoration of rights shall be sent to the GBI, so the database can be updated. Only the Certificate needs to be sent to the GBI and not the Guardianship Order.
According to Probate Court Rule 5.6 (A) unless the court specifically assumes the responsibility, it is the responsibility of the moving party to prepare the proper citation and deliver it properlyso that it can be served according to law. All pages after the Notice regarding Uniform Probate Court Rule 5.6 (A)are to be completed by the moving party, unless otherwise directed by the court.
An oath must be administered by a Probate Judge or Clerk (the oath cannot be administered by a notary public). Use Georgia Probate Court Supplement 4for the oath. The oath is not included in this form. Georgia Probate Court Standard Form 53, Commission to Administer Oath, can be used if the oath is to be administered by a court outside the State of Georgia.

General Instructions

General instructions applicable to all Georgia Probate Court Standard Forms are available in each Probate Court or at labeled GPCSF 1.

GPCSF 11[1]Eff. July 2016

IN THE PROBATE COURT OF ______COUNTY

STATE OF GEORGIA

IN RE:)

)

______, )ESTATE NO. ______

PROPOSED WARD)

PETITION FOR APPOINTMENT OF AN EMERGENCY GUARDIAN AND/OR EMERGENCY CONSERVATOR FOR A PROPOSED WARD

[NOTE: Unless there are two or more Petitioners, the affidavit beginning on page 11 must be completed by a physician, psychologist, or licensed clinical social worker and based on an examination within fifteen (15) days prior to the filing of this Petition.]

The Petition of ______,

whose relationship to the above-named Proposed Ward is______, whose

domicile is ______,

StreetCityCountyStateZip Code

and mailing address is ______,

StreetCityCountyStateZip Code

AND[initial either (a) or (b) below]

______(a)The Petition of ______,

whose relationshipto the above Proposed Ward is ______,

whose domicile is______,

StreetCity CountyStateZip Code

and mailing address is ______.

StreetCityCountyStateZip Code

______(b)Attached hereto as pages 11 and 12 and made a part of this Petition is the completed affidavit of______, a physician, psychologist licensed to practice in Georgia or licensed clinical social worker, who has examined the Proposed Ward within fifteen (15) days prior to the filing of this Petition, and shows to the Court the following:

The Proposed Ward

______

[Full name of Proposed Ward]FirstMiddleLast

whose age is ______, date of birth is ______,

Social Security Number is ______, domicile is

______

StreetCityCountyStateZip Code

presently located at ______,

StreetCityCountyStateZip Code

which is a [type of facility, if applicable]and can be contacted at telephone number: ______.

(a)Will the Proposed Ward be moved within the[Select One]□Yes □ No
next three (3) days?

(b)Is the Proposed Ward a citizen of a foreign country?[Select One]□ Yes □ No

If you answer“Yes” to (a)and/or (b), provide the necessary information below:

(a)The following is the address where the Proposed Ward is anticipated to be moved:

______

StreetCityCountyStateZip CodeTelephone Number

(b)The Proposed Ward is a citizen of a foreign country, said country being: ______(if an emergency guardianship or conservatorship is granted, pursuant to The Vienna Convention, the Probate Court must notify the consul).

Is an emergency guardianship necessary because the[Select One]□ Yes □ No

ProposedWard lacks sufficient capacity to make or communicate significant responsible decisions concerning his or her health or safety and there is animmediate and substantial risk of death or serious physical injury, illness, or disease unless an emergencyguardian is appointed?

Is an emergency guardianship necessary because the[Select One]□ Yes □ No

Proposed Ward lacks sufficient capacity to make or communicate significant responsible decisions concerning the management of his or her property and there is an immediate substantial risk ofirreparable waste or dissipation of the estate unlessan emergency conservator is appointed?

If you answer “Yes” to (a) and/or (b), provide the facts that support the claim of the need for an emergency guardian/emergency conservator (continued on next page):

[NOTE: Pursuant to O.C.G.A. §§ 29415(b) and 29514(b), the Court shall dismiss the Petition if the Petitioner(s) does/do not allege facts that cause the Court to believe that the Proposed Ward is in need of an emergency guardian/emergency conservator as stated above. The Petition cannot be granted unless sufficient facts are presented that support the claim for the need for the appointment of an emergency guardian/emergency conservator. While an attached physician’s, psychologists, or social worker’s affidavit is permissible, the Petitioner(s) MUST specifically allege sufficient facts to support the granting of this Petition.]

______

(a)It is in the best interest of the Proposed Ward for the following individual to be appointed emergency guardian: ______

(b)It is in the best interest of the Proposed Ward for the following individual to be appointed emergency conservator:______

(a)Is it necessary, in addition to the appointment of an [Select One]□ Yes □ No

emergency guardian, after notice and hearing, for the Court to immediately appoint a pre-hearing emergency guardian?

(b)Is it necessary, in addition to the appointment of an[Select One]□ Yes □ No

emergency conservator, after notice and hearing, for the Court to immediately appoint a pre-hearing emergency conservator?

If you answer “Yes” to (a)and/or (b), provide the following on a separate page:

The reasons why a pre-hearing emergency guardian/emergency conservator is necessary;
Who should be appointed as a pre-hearing emergency guardian/emergency conservator;
The specific powers that should be granted to the pre-hearing emergencyguardian and/or emergencyconservator; and
Why such powers are necessary to prevent irreparable harm to the Proposed Ward.

The reason(s) why the procedures for the appointment of a non-emergency (permanent) guardianship and/or conservatorship are inadequate to protect the Proposed Ward and/or his or her property is/are:

______

Will a petition for permanent guardianship/conservatorship be filed?[Select One]□ Yes □ No

If you answer “Yes,”provide the details of such filing, including thePetitioner’s name, county of filing, expected date of filing, etc.:

______

The foreseeable duration of the Proposed Ward’s incapacity is ______

______and the Court should grant the emergency guardian/conservator the following powers and duties that do not exceed those absolutely necessary to respond to the immediate threatened risk(s) described above:

______

(a)Has a Power of Attorney been created by anyone for the[Select One]□ Yes □ No

Proposed Ward?

(b)Has a trust been created by anyone for the proposed[Select One]□ Yes □ No

ward?

(c)Has another document been created by anyone that gives[Select One]□ Yes □ No

another person authority to act on the Proposed Ward’s

behalf?

(d)Does anyone else have the authority to act on behalf of[Select One]□ Yes □ No

the Proposed Ward?

If you answer “Yes” to (a), (b), (c) and/or (d),provide the following information:

The full name of eachindividualwith the authority to act under a power of attorney, trust, or otherwise. A name should be listed for each affirmative answer in this paragraph;
The complete address of each individualwith the authority to act under a power of attorney, trust, or otherwise. An address should be listed for each affirmative answer in this paragraph;
The telephone number of each individualwith the authority to act under a power of attorney, trust, or otherwise. A telephone number should be listed for each affirmative answer in this paragraph;
Attach a copy of each document that creates such authority; and

For each of the individuals named in this paragraph,state whether or not it appearshe or she is willing and able to act on behalf of the Proposed Ward and includethe facts that give rise to that appearance.

______

10.

[NOTE:If the appointment of an emergency conservator is sought and no petition forpermanentconservatorship is being filed simultaneously, this form must be completed.]

ASSETS, INCOME, OTHER SOURCES OF FUNDS, LIABILITIES, AND EXPENSES

OF PROPOSED WARD

REAL PROPERTY

[Indicate if property is jointly owned and, if so, with whom]

DescriptionCountyStateJoint Owner,Approximate Equity:

if any

Parcel 1: ______$______

Parcel 2: ______$______

Parcel 3: ______$______

INCOME FROM ALL SOURCES

Yearly Total:

Social Security per year:$______

SSI [Supplemental Security Income] per year:$______

Retirement benefits per year:$______

VA benefits per year:$______

Other income per year (e.g., alimony, annuity, or trust distributions):$______

Interest, dividend, or investment income:$______

Yearly Total of All Income:$______

Total of Income Covered by Conservatorship Period:$______

PERSONAL AND INTANGIBLE PROPERTY

[Indicate if property is jointly owned and, if so, with whom]

(1)Checking/Savings/Money Market/Certificates of Deposit/Liquid Accounts:

Bank/Financial Institution/BrokerAccount NumberJoint Owner,

if any

______$______

(2)Stocks/Bonds/Investments (including retirement and profit-sharing accounts):

(a)Held by Brokers:

Brokerage Firm/InstitutionAccount NumberJoint Owner,

if any

______$______

(b)Privately Held:

Company/IssuerNumber of SharesJoint Owner,

if any

______$______

(3)Automobiles

Year/Make/ModelV.I.N.Joint Owner,

if any

______$______

(4)Other assets of significant value:

DescriptionJoint Owner,if any

______$______

Total Value of Personal and Intangible Property:$______

DEBTS AND OTHER LIABILITIES

PERSONAL AND INTANGIBLE PROPERTY

The Proposed Ward has the following debts and/or liabilities:Approximate Balance:

(1)Secured Debts

Obligor/PayeeCollateralJoint Owner,if any

______$______

(2)Unsecured Debts

Obligor/PayeeAccount NumberJoint Owner,if any

______$______

Total Debts and Other Liabilities of Proposed Ward:$______

AVERAGE MONTHLY LIABILITIES AND EXPENSES

Household:

Care Facility/Rent/Mortgage Payments:$______

Property Taxes/Insurance:$______

Utilities/Lawn Care/Pest Control:$______

Miscellaneous Household Food:$______

Total Credit Account and Other Debt Payments:$______

Other [specify] ______:$______

Automotive/Transportation:

Fuel and Repairs:$______

Tags, License Fees, Insurance:$______

Bus/Train/Taxi Fares:$______

Minors or Other Dependents of Proposed Ward:

Childcare:$______

School Tuition/Supplies/Expenses/Lunches:$______

Clothing/Diapers/Grooming/Hygiene:$______

Medical/Dental/Prescription:$______

Other Insurance:

Health:$______

Life/Disability:$______

Other [specify] ______:$______

Proposed Ward’s Other Expenses:

Laundry/Clothing/Grooming/Hygiene:$______

Medical/Dental/Prescriptions/Medications: $______

Entertainment/Vacations/Subscriptions/Dues: $______

Personal Caretakers/Cleaning Personnel:$______

Total Expenses:$______

PAYMENTS TO CREDITORS

Is the Proposed Ward behind on any debt payments?[Select One]□ Yes □ No

If so, payee and amount: ______$______

SUMMARY

(1)Average Monthly Income:$______

(2)Average Monthly Expenses:$______

11.

This Court has jurisdiction to hear this action under Georgia law, and particularly under Chapters 4, 5, and 11 of Title 29 because: ______

______

12.

Additional Data: [Where full particulars are lacking, state here the reasons for any such omission.]

______

WHEREFORE, Petitioner(s) pray(s):

1.that service be perfected as required by law;

2.that the Court appoint legal counsel and an evaluator for the Proposed Ward and order an evaluation as required by law;

3.that the Court order an emergency hearing to be conducted not sooner than three (3) days nor later than five(5) days after the filing of this Petition;

4.that an emergency guardian/emergency conservator be appointed for the Proposed Ward; and

5.that, if requested, the Court immediately appoint a pre-hearing emergency guardian/emergency conservator with such powers and duties as the Court shall direct.

______

SignatureofFirstPetitionerSignatureofSecondPetitioner, ifany

______

PrintedNamePrintedName

______

MailingAddressMailingAddress

______

TelephoneNumberTelephoneNumber

Signature of Attorney______

Printed Name of Attorney______

Address______

______

Telephone Number ______State Bar #______

VERIFICATION

GEORGIA, ______COUNTY

Personally appeared before me the undersigned Petitioner(s) who, after being duly sworn, state(s) that the facts set forth in the foregoing Petition for the Appointment of an Emergency Guardian and/or Emergency Conservator for a Proposed Wardand the attached Exhibit(s) are true and correct.

Sworn to and subscribed before me this

______day of ______, 20____.______

Signature of First Petitioner

______

NOTARY/CLERK OF PROBATE COURT Printed Name of First Petitioner

My Commission Expires______

------

Sworn to and subscribed before me this

______day of ______, 20____.______

Signature of Second Petitioner

______

NOTARY/CLERK OF PROBATE COURT Printed Name of Second Petitioner

My Commission Expires ______

IN THE PROBATE COURT OF ______COUNTY

STATE OF GEORGIA

IN RE:)

)

______, )ESTATE NO. ______

PROPOSED WARD)

CONSENT TO SERVE AS EMERGENCY GUARDIAN/EMERGENCYCONSERVATOR

RE: Petition for the Appointment of an Emergency Guardian and/or Emergency Conservator for the above-named Proposed Ward

I, ______, having been nominated as emergencyguardian, and I,______,having been nominated as emergency conservatorof the above-named Proposed Ward, do hereby consent to serve as emergency guardianand/or emergency conservator and pre-hearing emergency guardian and/or pre-hearing emergency conservator if so appointed.

______

Signature Proposed Emergency GuardianSignature Proposed Emergency Conservator

______

PrintedNamePrintedName

______

MailingAddressMailingAddress

______

TelephoneNumberTelephoneNumber

IN THE PROBATE COURT OF ______COUNTY

STATE OF GEORGIA

IN RE:)

)

______, )ESTATE NO. ______

PROPOSED WARD)

RE:Petition for Appointment of an Emergency Guardian and/or Emergency Conservator for the above named Proposed Ward

AFFIDAVIT OF PHYSICIAN, PSYCHOLOGIST, OR CLINICAL SOCIAL WORKER

FOR EMERGENCY GUARDIANSHIP AND/OR EMERGENCY CONSERVATORSHIP

I, being first duly sworn, depose and say that I am a physician licensed to practice under Chapter 34 of Title 43 of the Official Code of Georgia Annotated, a psychologist licensed to practice under Chapter 39 of Title 43 of the Official Code of Georgia Annotated, or a licensed clinical social worker; that my office address is______and that I have examined the above-named Proposed Ward on the______day of ______, 20____.

[NOTE: The examination on which this affidavit isbased must occur WITHIN FIFTEEN (15) DAYS prior to the filing of the Petition.]

I found him/her to be incapacitated by reason of:

______

to the extent that saidProposed Ward:

[initial all applicable]

______(a) [foremergency guardianship:] lacks sufficient capacity to make or communicate significant responsible decisions concerning his or her health or safety and there is an immediate and substantial risk of death or serious physical injury, illness, or disease unless an emergency guardian is appointed, and [if applicable]

______(i) the threatened risk is so immediate and the potential harm so irreparable that any delay is unreasonable and a pre-hearing guardian should be appointed.

______(b) [foremergency conservatorship:] lacks sufficient capacity to make or communicate significant responsible decisions concerning the management of his or her property and there is an immediate, substantial risk of irreparable waste or dissipation of the estate unless an emergency conservator is appointed, and [if applicable]

______(ii) the threatened risk is so immediate and the potential harm so irreparable that any delay is unreasonable and a pre-hearing conservator should be appointed.

The following facts support my opinion of incapacity and the existence of(an) immediate threat(s) or risk(s) to the Proposed Ward: ______